Belle Vie Glow Pre-Consultation Form

Belle Vie Glow

Pre-Consultation Form
Name

First NameLast Name
Date of birth

DayMonthYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Have you had a patch test? **Recommended for pregnant women or those with sensitive skin

YesNo
If not please confirm you are happy to proceed with your treatment

Yes, I am happy to proceedNo, I will reschedule
Have you had any surgery or medical treatment in the last 12 months? If Yes, please explain
Do you suffer with any respiratory problems?

YesNo
Are you pregnant or breastfeeding?

YesNo
Do you have any skin or pigmentation disorders?

YesNo
Is your skin hypersensitive?

YesNo
Have you any known allergies?

YesNo
If yes please specify:
Have you any open cuts/wounds/rashes?

YesNo
Have you recently had any body piercings or tattoos?

YesNo
Have you had any recent Botox or fillers?

YesNo
Is the tan for a special occasion?

YesNo
If yes, what will you be wearing for the occasion? For example, strapless gown, swimsuit, etc.
Have you had a spray tan or used tanning products before?

YesNo
What was your experience?
What is your skin tone?

Very lightLightMediumDarkVery Dark
What tan would you like to achieve?
Any questions?
Disclaimer: I declare that I have read and understood and answered the questions to the best of my knowledge. I have no known medical conditions or allergies that may affect or induce a harmful reaction from a sunless tanning treatment.

The information above is for Belle Vie Glow records only and will not be misused or passed on to any other third-parties.
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